[Outcomes following the triage of patients for urological cancer and non-cancer surgery during Covid-19 pandemic peak]. / Évaluation des mesures de triages de la première vague pandémique Covid-19 pour sélectionner les patients à opérer pour cancers et urgences urologiques.

INTRODUCTION: Faced with the first wave of Covid-19 pandemic, guidelines for surgical triage were developed to free up healthcare resources. The aim of our study was to assess clinical characteristics and surgical outcomes of triaged patients during the first Covid-19 crisis. METHOD: We conducted a cohort-controlled, non-randomized, study in a University Hospital of south-eastern France. Data were collected prospectively from consecutive patients after triage during the period from March 15th to May 1st and compared with control data from outside pandemic period. Primary endpoint was intensive care unit (ICU) admissions for surgery-related complications. Rates of surgery-specific death, postponed operations, positive PCR testing and Clavien-Dindo complications and data from cancer and non- cancer subgroups were assessed. RESULTS: After triage, 96 of 142 elective surgeries were postponed. Altogether, 71 patients, median age 68 y.o (IQR: 56-75 y.o), sex ratio M/F of 4/1, had surgery, among whom, 48 (68%) had uro-oncological surgery. No patients developed Covid-19 pneumonia in the post-surgery period. Three (4%) were admitted to the ICU, one of whom died from multi-organ failure due to septic shock caused by klebsiella pneumonia following a delay in treatment. Three Covid-19 RT-PCR were done and all were negative. There was no difference in mortality rates or ICU admission rates between control and Covid- era patients. CONCLUSIONS: Surgery after triage during the first Covid-19 pandemic was not associated with worse short-term outcomes. Urological cancers could be operated on safely in our context but delays in care for aggressive genitourinary diseases could be life threatening. LEVEL OF EVIDENCE: 3.

The clinical impact of the COVID-19 pandemic on daily urological practice: first 3-month multicenter results from Istanbul

Background/aim: The aim of this paper was to determine the general tendencies of urology patients and effect of COVID-19 pandemic on daily urological practice at tertiary centers located in the most affected area in Turkey. Materials and methods: We retrospectively analyzed the data of 39,677 patients (group 1) that applied to 6 different large-volume tertiary centers in Istanbul for outpatient consultation, surgery, or other procedures in the 3-month period between March 16 and June 14, 2020. The distribution of the number of patients who applied to subspecialty sections of urology outpatient clinics and inpatient services were recorded by weeks. That data was compared to data obtained from 145,247 patients that applied to the same centers in the same period of the previous year (group 2). The reflection of worldwide and Turkish COVID-19 case distribution on the daily urological practice was analyzed. Results: There was a decrease in the number of patients in all subspecialty sections the in group 1 compared to group 2; however, there was a significant proportional increase in urooncology and general urology admissions. A decrease of approximately 75% was observed in the total number of surgeries (p < 0.001). We detected a negative correlation between the numbers of admission to all outpatient clinics and COVID-19 cases or deaths in Turkey (p < 0.05). The same negative correlation was present for all surgical procedures and consultations (p < 0.05). The multivariate linear regression analysis revealed that the number of cases in Turkey, and the number of deaths worldwide affect the number of outpatient clinic admissions (R2 = 0.38, p = 0.028) and urological surgery (R2 = 0.33, p = 0.020) in Turkey negatively. Conclusion: This novel pandemic has implications even for urology practice. Urological surgical procedures were more affected by COVID-19-related deaths in Turkey and worldwide. Outpatient admissions and urological surgeries decreased significantly by increasing COVID-19 case numbers in Turkey and worldwide deaths.

Urological emergency activities during COVID-19 pandemic: Our experience.

BACKGROUND: The Coronavirus Disease (COVID-19) is causing a significant health emergency which is overturning dramatically routine activities in hospitals. The outbreak is generating the need to provide assistance to infected patients and in parallel to treat all nondeferrable oncological and urgent benign diseases. A panel of Italian urologists agreed on possible strategies for the reorganization of urological routine practices and on a set of recommendations that should facilitate a further planning of both inpatient visits and surgical activities during the COVID- 19 pandemic. According to this only urgent benign and nondeferrable oncological activities have been kept. MATERIALS AND METHODS: We have considered urgent outpatient visits requested by Emergency Department (ED) or by General Practitioner (GP) and emergency surgical procedures performed in our Urology Unit from March 9th to April 14th 2020, during COVID-19 pandemic. These figures have been compared to those observed last year from March 9th to April 14th 2019. RESULTS: Our data show that urgent care visits decreased during COCID-19 pandemic (from 293 to 179). Urgent care visits of patients who accessed directly to the ED decreased (from 219 to 107) whereas the number of urgent care visits referred by GP remained unchanged (74 vs 72). Consequently, the rate of visits from ED decreased from 75% to 60% and the rate of visit requested by GP increased from 25% to 40% (p = 0.001). Particularly, the rate of visits for renal colic, LUTS and other not precisely defined disorders from ED decreased and the corresponding rates of visits of patients referred by GPs increased significantly (p = 0.0001, p = 0.0180 and p = 0.0185, respectively). The rate of visits for acute urinary retention, hematuria, sepsis, acute scrotum, cystitis, prostatitis and genito-urinary trauma from ED and GP remained unchanged. Finally, urgency endourology and surgical activities have been stable in relation to the same period last year. CONCLUSIONS: Urological emergency activities during COVID- 19 pandemic are more appropriate since urgent outpatients' visits required by ED are decreased and emergency surgical and endourological procedures are stable.

Non-COVID Diseases during the Pandemic: Where Have All Other Emergencies Gone?

Background and objectives: the emergency department (ED) is frequently identified by patients as a possible solution for all healthcare problems, leading to a high rate of misuse of the ED, possibly causing overcrowding. The coronavirus disease 2019 (COVID-19) pandemic started in China; it then spread throughout Italy, with the first cases confirmed in Lombardy, Italy, in February 2020. This has totally changed the type of patients referred to EDs. The aim of this study was to analyze the reduction of ED admissions at a Second level urban teaching (Fondazione Policlinico Universitario Agostino Gemelli IRCCS) during the COVID-19 pandemic. Materials and Methods: in this retrospective observational cross-sectional study, we reviewed and compared clinical records of all the patients consecutively admitted to our ED over a 40-day period (21 February -31 March) in the last three years (2018-2019-2020). Mean age, sex, triage urgency level, day/night admission, main presentation symptom, and final diagnosis, according to different medical specialties, hospitalization, and discharge rate, were analyzed. Results: we analyzed 16,281 patient clinical records. The overall reduction in ED admissions in 2020 was 37.6% compared to 2019. In 2020, we observed an increase in triage urgency levels for ED admissions (the main presentation symptom was a fever). We noticed a significant drop in admissions for cardio-thoracic, gastroenterological, urological, otolaryngologic/ophthalmologic, and traumatological diseases. Acute neurological conditions registered only a slight, but significant, reduction. Oncology admissions were stable. Admissions for infectious diseases were 30% in 2020, compared to 5% and 6% in 2018 and 2019, respectively. In 2020, the hospitalization rate increased to 42.9% compared to 27.7%, and 26.4% in previous years. Conclusions: the drastic reduction of ED admissions during the pandemic may be associated with fear of the virus, suggesting that patients with serious illnesses did not go to the emergency room. Moreover, there was possible misuse of the ED in the previous year. In particular, worrisome data emerged regarding a drop in cardiology and neurology admissions. Those patients postponed medical attention, possibly with fatal consequences, just for fear of exposure to COVID-19, leading to unnecessary morbidity and mortality.

Benefits and barriers to pediatric tele-urology during the COVID-19 pandemic.

INTRODUCTION: Telemedicine video visits are an under-utilized form of delivering health care. However due to the COVID-19 pandemic, practices are rapidly adapting telemedicine for patient care. We describe our experience in rapidly introducing video visits in a tertiary academic pediatric urology practice, serving primarily rural patients during the COVID-19 pandemic. OBJECTIVE: The primary aim of this study was to assess visit success rate and identify barriers to completing video visits. The secondary aim identified types of pathologies feasible for video visits and travel time saved. We hypothesize socioeconomic status is a predictor of a successful visit. MATERIALS AND METHODS: Data was prospectively collected and analyzed on video visits focusing on visit success, defined by satisfactory completion of the visit as assessed by the provider. Other variables collected included duration, video platform and technical problems. Retrospective data was collected via chart review and analyzed including demographics, insurance, and distance to care. Socioeconomic status was estimated using the Distressed Communities Index generated for patient zip code. RESULTS/DISCUSSION: Out of 116 attempted visits, 81% were successful. The top two reasons for failure were "no-show" (64%) and inability to connect (14%). Success versus failure of visit was similar for patient age (p = 0.23), sex (p = 0.42), type of visit (initial vs. established) (p = 0.51), and socioeconomic status (p = 0.39). After adjusting for race, socioeconomic status, and type of provider, having public insurance remained a significant predictor of failure (p = 0.017). Successful visits were conducted on multiple common pediatric urologic problems (excluding visits requiring palpation on exam), and video was sufficient for physical exams in most cases (Summary Table). A median of 2.25 h of travel time was saved. CONCLUSIONS: While socioeconomic status, estimated using the Distressed Communities Index, did not predict success of video visits, patients with public insurance were more likely to have a failed video visit. There is compelling evidence that effective video visits for certain pathologies can be rapidly achieved in a pediatric urology practice with minimal preparation time.

Increased Use of Blood Transfusions to Manage Urological Conditions during the COVID-19 Pandemic.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to an extensive reorganization of the healthcare system in Italy, with significant deferment of the treatment of urology patients. We aimed to assess the impact of deferred treatment during the SARS-CoV-2 pandemic on the need for blood transfusions in 3 Italian urology departments. METHODS: We reviewed hospital chart data on blood transfusions at the urology units of 3 academic centers in the north of Italy from March to April 2020. Data were compared with values from the same time frame in 2019 (March to April 2019). RESULTS: We observed significant reductions of the number of patients admitted to the urology units from March to April 2020 (373 vs. 119) and the number of performed surgeries (242 vs. 938) compared to 2019. Though, the number of transfused blood units was comparable between the 2 years (182 vs. 252), we found a greater mean number of blood units transfused per admission in 2020 (0.49 vs. 0.22; p < 0.0001). As a whole, the transfusion rate for hematuria was higher in 2020 than in 2019 (36 vs. 7.9%; p < 0.0001). DISCUSSION/CONCLUSION: The observed increased number of blood transfusions needed throughout the SARS-CoV-2 era could have had a negative impact on both patients and the healthcare system. It is possible to speculate that this is the consequence of a delayed diagnosis and deferred treatment of acute conditions.

Urologists and the Novel Coronavirus Disease 2019 (COVID-19): a Urologist's Perspective from China.

No need for letter to the editor.

Being a Urologist on COVID-19 Pandemic Days.

...

Preliminary assessment of patient and physician satisfaction with the use of teleconsultation in urology during the COVID-19 pandemic.

PURPOSE: Lockdown during the COVID-19 pandemic compelled urologists to change access to healthcare, especially for oncology patients. Teleconsultation is a safe way to receive medical advice without a risk of infection, and was implemented urgently in our academic centres. Our purpose was to evaluate patient and physician satisfaction with teleconsultation set up during the COVID-19 pandemic. METHODS: From March 16th 2020, all face-to-face consultations were cancelled in France, except for emergencies. Teleconsultation was started immediately by five senior urologists in two academic hospitals. All patients received an email survey including the validated Teleconsultation Satisfaction Questionnaire (TSQ) and demographic questions. Data were collected prospectively. Physicians also responded to the TSQ. Patient satisfaction was measured objectively with the validated 14-item TSQ. Each item was scored on a 5-point Likert scale. Factors associated with positive satisfaction with teleconsultation were assessed by multivariable logistic regression. RESULTS: Overall, 105 patients replied to the survey (91.3%). Median age was 66 years (IQR: 55‒71) and 95 were men (90.5%). Median overall TSQ score was 67 (IQR: 60‒69); teleconsultation was judged to be a good experience by 88 patients (83.8%) and four physicians (80%). Patients who met their surgeon for the first time were more likely to have a good experience (OR = 1.2 [95% CI 1.1‒1.5], p = 0.03). CONCLUSION: Introduced rapidly during the COVID-19 lockdown, urology teleconsultation attained a high level of satisfaction among both patients and physicians. A major change in telemedicine use is foreseen in the post COVID-19 era.

What has changed during the state of emergency due to COVID-19 on an Academic Urology Department of a Tertiary Hospital in Portugal. / Los cambios producidos durante el estado de alarma debido a la COVID-19 en un Servicio de Urología de un Hospital Universitario Terciario en Portugal.

OBJECTIVE: To compare the activity the Urology Department of a Portuguese Academic Hospital during the state of emergency and the equivalent period at the previous year. We compared the number of elective consultations and diagnostic urologic examinations, number and type of elective surgeries, as well as patients' demographic characteristics and main causes of presentation to Urology Emergency Department (ED) during the two mentioned periods MATERIALS AND METHODS: Data from 691 patients coming to emergency department were collected from institutional clinical software from March 18 th 2020 to May 2 nd 2020 - and from the same period the previous year. Data collected were age, sex, day of the presentation to Emergency Department, referral from other hospitals, triage color, reason of admission, diagnosis of discharge, and the need for emergency surgery or hospitalization. In order to identify associations between demographic and clinical variables with having been submitted to an emergency surgery (outcome), logistic regression models were applied. RESULTS: Multivariable analysis showed an association of sex with being submitted to surgery, 65.6% decrease in the odds for the male gender. The period (COVID versus non-COVID) did not show a significant association with surgery. CONCLUSION: Our department experienced a noticeable activity reduction. We also observe a reduction in urgent causes to attend the ED considered less serious. The percentage of cases requiring emergency surgery and hospitalization was higher during COVID-period.

Urology during a Crisis: A Management Algorithm.

COVID-19 pandemic has affected more than a million people worldwide causing a public health crisis. Under these unique circumstances, urologists continue to provide essential healthcare services and support healthcare systems, by participating in the treatment of COVID-19(+) patients and sparing vital equipment and hospital beds. However, delivering medical care during the pandemic requires strategic planning for all surgical and outpatient activities. Proposed measures include rescheduling elective non-oncological surgeries and using a prioritization protocol for oncological surgeries according to hospital capacity. Following that, outpatient clinics could be partly replaced by telemedicine. Additionally, urologists should be trained in screening and treating patients with COVID-19 during their daily routine.  In order to efficiently provide their services, a management protocol for suspected or known COVID-19 urological patients should be implemented. Furthermore, preventive measures for the nosocomial dispersion of the virus and training on self-protective equipment is mandatory for all physicians. Finally, organizational planning for the best utilization of the staff is of utmost importance. Implementation and adaptation of the protocols according to local requirements and guidelines will ameliorate the quality of services and population's health status. Finally, enhancement of current practices will prepare health systems for future crisis.

Management of Patients Who Seek Urologic Care in Covid-19 Pandemic Era.

INTRODUCTION:  Novel coronavirus Disease (Covid-19) has emerged in Wuhan, China in December 2019 and became a pandemic in a few weeks. In this review, we aimed to summarize the current urologic practice trends worldwide to help urologist in decision making in disasters particularly in Covid-19 pandemic. MATERIAL AND METHOD:  We have performed a PubMed and Internet search by using the keywords: 'Covid', 'new coronavirus', 'coronavirus urology, 'covid urology' without a date restriction.  Results: All elective surgeries for benign urological conditions such as urinary tract stone disease that not caused complicated obstruction, benign prostate enlargement, infertility, incontinence and genitourinary prolapse, erectile dysfunction undescendent testis, vesico-ureteral reflux   should be postponed till the lasting of Covid-19 outbreak. In obstructing ureteral stone both nephrostomy tube and double-J stent insertion are valid management options. However, one must consider that these procedures must be performed under local anesthesia when possible to spare a ventilator. When deferring urooncological operations and treatments oncological outcomes must be considered. Aggressive cessation or reducing the dosage of immunosuppressant therapy might be an option in renal transplanted patients with severe pneumonia or acute respiratory distress syndrome.

Iranian Urology Association Coronavirus Disease 2019 (COVID-19) Taskforce Pamphlet (IUA-CTP) Recommended Practice based on National Epidemiologic Analysis.

Since the emergence of Covid19 epidemics different guidelines and protocols have been published by Urology associations. Most of these recommendations have focused on the aptitude of any disease or condition for postponement. With the evolution of the outbreak, it is clear that postponement of procedures is not the policy we can rely on exclusively. We must know where do we stand? Where are we going in our country? How useful our recommendations have been for urology practitioners? We try to draw a clearer although-to some extent- conjectural picture and to adjust our protocols to this picture of outbreak evolution. Assuming that anything in this predicament is subject to unexpected changes. For these goals, we raise these arguments in three sections. First, where do we stand and where are we going? Explaining the present situation and best available statistics of the disease, the velocity the disease is spreading and our approximate predicted date its subsidence or partial remission. In a web form survey, we tried to evaluate that in the absence of a clear picture of outbreak progress in a specific area, how useful experts' points of view will be for the urologists working in non-referral centers especially in relevance to equivocal and challenging cases. Will there be any significant difference at all? In the third section, we try to give the plot to guide scheduling or postponing procedures in any given are according to the level of involvement. Here we considered both the characteristics of the special urology condition and also the situation and progress of the outbreak in that area.

Urological Services in the Era of COVID-19.

INTRODUCTION: On 11 March 2020, the World Health Organization (WHO) declared a pandemic. Since then hospitals have reduced inpatient and outpatient workflow and cancelled or suspended all non-emergent and routine surgical procedures. Our objective is to determine whether, during the COVID-19 period, there has been any modification in urological services. MATERIALS AND METHODS: We retrospectively studied the data from January-May 2020 and 2019 about the variables: number of operations, waiting list, visits in outpatient department, bladder instillations and urological emergencies and admission rates. RESULTS: Cancer cases high-risk for stage progression and surgical emergencies, were elected to proceed directly to treatment. The number of the operations was reduced by 43-65% from March-May 2020. Our surgical list had a waiting time of 6-8 weeks before the pandemic and now the waiting time has expanded to 12 weeks. Urological emergencies were reduced about 23-57%. Admission rates were dropped 10-51%. Visits in outpatient clinics were reduced 100-50% and outpatient procedures for elective cases were all deferred. Unfortunately, the hospital did not offer synchronous telehealth appointments. Bladder instillations of BCG or chemotherapeutics were not suspended but start of new cases had a delay of 2-3 weeks. There were no cases of COVID-19 in our department. CONCLUSION: All the variables of our urologic practice were affected during the COVID era. The impact of the reduced model of outpatient and inpatient workflow on the health of our patients is unknown. However, longer waiting lists are expected. It is obvious that healthcare providers should adopt a new healthcare model.

Clinical Features Deserve Consideration for a Urologist in COVID-19.

We have studied up-to-date knowledge about the clinical feature of the Novel coronavirus pandemic worth consideration by the urologist. PubMed database, the United States centers for disease control and prevention (CDC), and the World Health Organization (WHO) websites were also accessed. A staging system introduced by Siddiqi et al. for the COVID-19 is acknowledged. Hemodialysis centers are high-risk zones in the outbreak of a COVID-19 epidemic. Symptoms and signs, clinical features, and laboratory findings of the renal transplant patients are almost similar to non-transplanted patients.